الفهرس 
Introduction and aim of the workOnly 14 pages are availabe for public view
 |  | from | 145 |  |  |
| | | from | 145 | | |
Abstract
This prospective study was carried out on patients with liver cirrhosis admitted to chest, tropical medicine and gastroenterology departments, Sohag University Hospitals during the period from October 2017 to October 2018 and included 105 patients, 53.3% were males and 46.7% were females with a mean age 59.7±17.7 years. 12.4% of patients died.
87.6% of studied patients had no previous chronic chest problems, 16% were diabetic and 9.5% were hypertensive.
88.5% had right pleural effusion, 7.6% had left pleural effusion and 3.8% had bilateral pleural effusion. 80% presented with mild pleural effusion, 13.3% with moderate amount, 4.7% with marked amount and 1.9% with massive pleural effusion.
The mean Child Pugh score in studied patients was 9.9, 30.5% had Child Pugh class B and 69.5% had class C.
The incidence of SBEM in studied patients was 13.33%. 22.86% of patients had SBP. SBP was associated with increased risk of SBEM as more than 57% of patients with SBEM had concomitant SBP (P value 0.002).
There was no relationship between either laterality or amount of pleural effusion and the incidence of SBEM.
There was an increased risk for SBEM with high Child Pugh score and class (P value <0.0001 and 0.006 respectively).
57.14% of patients with SBEM had positive pleural fluid culture. E. Coli was the most common organism responsible for SBEM accounting for 50% of cases of culture positive SBEM followed by Klebsiella (25%), Enterococcus and streptococcus spec. (12.5% each).
All cases which showed bacterial growth in their pleural fluid cultures were sensitive to Meropenem (100%), followed by Ceftriaxone and Ciprofloxacin (62.5 each) and Levofloxacin and Cefotaxime (50% each).
There was a significant relationship between presence of chest pain, fever, cough, abdominal pain and septic shock and the incidence of SBEM.
67.6% of patients were presented with hepatic encephalopathy, 38% with grade II, 33.8% with grade III and 28% with grade IV. There was no significant relationship between presence of or grade of hepatic encephalopathy and increased incidence of SBEM.
There was a significant relationship between presence of leukocytosis and SBEM.
Also there was a significant relationship between lower serum albumin level, low serum total protein level and prolonged INR and increased incidence of SBEM.
Regarding pleural fluid analysis, low pleural fluid protein, high pleural fluid WBCs count, high polymorphs count, low glucose level and high LDH level were associated with increased risk of SBEM.
Presence of SBP, low serum albumin level, low pleural fluid protein level, high Child Pugh score and prolonged INR are independent risk factors for the development of SBEM.
In case of SBEM either confirmed or suspected, therapy with the appropriate antibiotics should be started immediately such as 3rd generation cephalosporins as Ceftriaxone and Cefotaxime or quinolones as Ciprofloxacin or Levofloxacin.
SBEM is a serious condition that may lead to mortality if not diagnosed or if diagnosed lately. 35.7% of patients with SBEM died versus 8.7% of patients with sterile hepatic hydrothorax.
Conclusions
from this study we can conclude that:
1. SBEM is a common complication in patients with liver cirrhosis and hepatic hydrothorax.
2. SBEM is commonly right sided and associated with mild amount of pleural effusion.
3. Patients with liver cirrhosis and SBEM are commonly presented with chest pain, fever, cough, abdominal pain and septic shock.
4. SBEM is better diagnosed by cytological examination of pleural fluid. Positive pleural fluid culture is not usually present in all patients.
5. Many risk factors can contribute to the development of SBEM such as presence of SBP, low serum albumin level, low pleural fluid protein level, advanced liver disease as expressed by high Child Pugh score and class C Child Pugh class and prolonged INR.
6. SBEM is a risk factor for increased mortality in patients with liver cirrhosis and hepatic hydrothorax.
Recommendations
Pleural thoracentesis should be done routinely in cirrhotic patients presented with pleural effusion especially in patients who had one or more of the forementioned risk factors for development of SBEM.
Early antibiotic therapy is advisable to guard against the complications caused by SBEM including mortality
Effort should be made to eliminate or decrease the risk factors for SBEM especially in patients with history of SBEM before to guard against future events.
The incidence and mortality rate of SBEM are still high and increasing. Further studies should be done to assess more risk factors for the development of SBEM and discover new treatment modalities that lead to better outcome in SBEM patients.